Volume 103, Issue 3 (2004)

Editorials

A journal with a readership the size of the Wisconsin Medical Journal seldom has the privilege of publishing what we believe is a substantial contribution toward the improvement of the care of a significant number of patients. We believe that the report of the Wisconsin Medical Society’s Task Force on Chronic Pain Management is one of those occasions.

The article by Bartell and Smith, in this issue of the Wisconsin Medical Journal, which looks at the relationship between physicians’ professionalism and quality improvement as it has evolved to date, is an excellent summary addressing the issues as seen from a physician’s perspective up to this point. In addition, the article provides a good summary of the systems approach for a potential solution to providing optimal health care, which fits well with the physician’s role.

Original Research

Over the past 15 years, there has been increasing discussion about “paying for results” or “value purchasing,” 1-3 which means getting the best care for the best price. However, most emphasis has been focused on reducing costs, with little attention paid to quality or outcomes. This is in part due to the lack of standardized measures, but also there is limited experience with effective financial incentives for providers. There has been speculation that the barriers to real accountability may be much stronger than the desire to purchase for value.

In health care, voluntary disclosure of outcome data can add and create credibility, a sense of integrity, and an urgency to improve, both internally and externally. This was the philosophy around which nine physician-led health care organizations and their employer-partners rallied in October 2002 to form the Wisconsin Collaborative for Healthcare Quality (Collaborative). They set out to prove that seven hospitals, six multi-specialty physician groups, four health plans and nine employer partners from across the state could agree upon the mutually beneficial goal of increased transparency and work collaboratively to achieve it. Together, they produced the first Performance and Progress Report, released after one year.

March 30, 2004 marked the culmination of 18 months of intense effort to be among the first states to create a hospital public quality and safety reporting program. And the fact that virtually all Wisconsin hospitals volunteered to participate says a lot about what physicians, staff, and hospital executives hold as central to their professional being high quality, safe care for their patients.

Just as some people are healthy and others are not, the “health” of communities also varies. The Wisconsin Public Health and Health Policy Institute recently released its first annual Wisconsin County Health Rankings (2003 edition, available at http://www.pophealth.wisc.edu/wphi/) which describes, using publicly available data, some of the variation in several measures of population health. This brief report introduces the County Health Rankings and presents a subset of the rankings pertaining to summary measures of population health “outcomes” and “determinants.”

Five years ago I was asked to participate in a collaborative group in the Milwaukee area on preventive guidelines. The goal, I was told, was to improve quality by achieving consensus among the 13 represented health care entities on a single set of preventive guidelines. Having just completed a survey among my own faculty group and discovering that we had at least as many opinions as faculty in this area, I found the whole idea quite amusing, though unrealistic, and decided I couldn’t pass up the opportunity to participate.

Almost 100 years have passed since E. A. Codman advocated evaluation of care provided to patients. Donebedian provided a set of criteria for measuring quality, and the Institute of Medicine provided a definition of quality.

The issue of physician professionalism has grown in importance in recent years, in part because of perceptions that our rapidly changing health care system and the incentives associated with managed care threaten professionalism. Inherent conflicts between physician professionalism and the financial and non-financial incentives used by health care organizations in quality management may be undermining the effectiveness of quality improvement initiatives. This paper examines the role of system redesign in quality improvement and the implications of a systems approach for physician job satisfaction, professionalism, and the quality of patient care. We contend that a systems perspective may be more compatible with physician professionalism and may be a more effective method of quality improvement that could alleviate some of the resistance that accompanies the implementation of quality improvement efforts. Disease management programs and multidisciplinary patient care teams are discussed as examples of potentially useful system-level interventions.

Problem: Diabetes is a chronic and costly disease affecting approximately 330,000 people in Wisconsin. This study examined the association between use of clinical practice guidelines and outcomes of care.

Methods: Fourteen physicians from 3 diverse sites volunteered to recruit their adult patients with type 1 and type 2 diabetes who were in continuous care in 1999 and 2000. Of 757 randomly selected patients, 492 (65%) completed a mailed survey and 471 (62%) also gave consent for medical record review. Measures included diabetes management indicators, SF-36 scores, and patient satisfaction.

Results: Respondent age averaged 63 years (range 22-90 years) and 55% were men. While most clinicians measured blood pressure, lipids, and hemoglobin (A1c), less than half of the patients were at goal for these indicators. The process indicators explained a significant amount of the variability in physical functioning after controlling for demographics, comorbidities, diabetes-related factors, and clinician type. Overall, most respondents rated their diabetes care as excellent or very good and would recommend their clinician to family and friends.

Your Practice

Do you own your practice? Have you considered the impact your death, disability, or retirement could have on your business? Have you formulated a plan to transfer your business interest in order to achieve maximum value?

Your Profession

The explosion of biomedical information in the past two decades or so has created attractive new opportunities for treating and preventing human diseases. But the new body of knowledge which will only continue to expand—also presents health care providers enormous new challenges.

Your Society

House of Delegates2004 House of Delegates Action on Resolutions and Board Reports
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